PROVIDER TRAINING MANUAL

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Nov 17, 2013 (4 years and 1 month ago)

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PROVIDER
TRAINING

MANUAL


VETERANS EVALUATION SERVICES

VA COMPENSATION AND PENSION
EXAMS

“Never believe that a few caring people can’t change the world.
For, indeed, that’s all who ever have.”

Margaret Mead



WELCOME…


…to the Veterans Evaluation Servic
es (VES) division of MES
Solutions! We're glad you're here.

We are very excited to have you working with us and assisting
us in providing our veterans/active duty service members with
quality disability evaluations.

It is an honor to work hand in hand wit
h our providers to ensure
our claimants are evaluated with respect and dignity. This is our
opportunity to give back to all of the individuals who have
sacrificed so much for our country.

We welcome your comments and suggestions as this will assist
us in i
mproving and enhancing our services for all of our
veterans and active duty service members.

Again, thank you for your contribution to this worthy endeavor.


April and Lauren

April Harris and Lauren Sparkman

Associate Directors of Development & Training

I
NTRODUCTION

MES has a contract with the United States Department of Veteran Affairs, the VA. We
are providing compensation and pension exams for veterans and active duty service
persons.

Compensation

is a monetary benefit for physical or mental disabiliti
es related to military
service.

Pension

is more like a welfare benefit
-

it's paid to certain veterans who are too disabled
to work. Their disabilities may or may not be due to military service. We won't see a lot of
requests for pension exams. VA can ofte
n grant pension benefits without having to
examine the veteran.

AMIE Worksheets
: AMIE stands for Automated Medical Information Exchange which is
VA software. VA created the AMIE worksheets to guide the examiner to obtain a report
needed to make a legal dec
ision about a claimant’s entitlement to monetary benefits and
disability.

There are more than 50 different worksheets for the various body systems and
disabilities. The worksheets we will provide you are based on the VA AMIE worksheets
and will be customi
zed for the claimant you will be examining.

You may be evaluating a condition that is being claimed for the first time or one that has
already been connected to military service by the VA, also known as established. If the
VA denies a veteran’s claim he/s
he may appeal that decision. Providers may be asked
to conduct exams on appeal cases including a special appeal called a remand. You
may also sometimes be asked to render a formal medical opinion which will require
review of medical records. For some case
s you will be asked to review medical records.
We will never send you the actual VA claims file (C
-
file), but we will provide you with the
pertinent records from that file. The VA may ask the provider to examine a claimant if his
condition is subject to im
provement.

Our VA contract requires us to reimburse claimants for mileage. If an MES staff member
is manning your front desk, he or she will disburse the checks to the claimants.
Otherwise, we will mail the check to the claimant after the appointment.

A v
eteran or active duty service person might ask "When do you think VA will make a
decision on my claim?" or "Do you think the VA will grant my claim? What rating or
percentage do you think I will get?” Neither you nor MES has any way of knowing the
answers
to these questions, so the best response is to refer the claimant to VA’s toll
-
free
number: 1 (800) 827
-
1000.

In general, please avoid discussing or addressing the following during the exam
:



The merits of the claim.



Percentage evaluations.



Likely outcome
or benefits as a result of examination.



Incurrence or aggravation of disability in service
-

unless a specific
question concerning those issues has been asked by the regional office.



Possible treatment options not yet tried.



Correctness of the current eva
luation.



Correctness of a determination that a disability is or is not service
-
connected.



Treatment recommendations.



Promoting the sale of products or services i.e. hearing aids.



Politics.

VA offers a wide variety of healthcare and other benefits to veter
ans. 1 (800) 827
-
1000
is the best way to refer a veteran to VA for more information.

Evaluation vs. Treatment: Your report will be used by the VA to make a decision on a
claim for disability benefits. You are evaluating the claimant’s disabilities, not tre
ating the
patient.

Our VA contract has very strict deadlines. Your contract requires submission of your
completed report to MES within 48 hours of the exam.

Outstanding customer service is crucial to the success of this contract. Your
compassionate bedside

manner will help to ensure a positive experience for the
claimant.

Also,
please make sure your office does NOT send the claimant a bill for any services
.
MES will pay you.
The claimant must not be billed.

If you have any billing questions,
please call 1
(877) MES
-
VETS.

Our quality assurance staff will work closely with you to address any missed
information, inconsistencies, or gray areas in your report. QAs exist to ensure
your reports will meet all of VA’s complex requirements prior to delivery.

And fina
lly, MES welcomes and appreciates your feedback on our worksheets,
software and operations.





OUR COMPANY

1) HISTORY: Here is a brief history of the company from www.mesgroup.com:


MES Solutions, (MES) was founded in 1978 and was the first organizat
ion ever established to
provide the claims community with access to physicians with expertise in conducting Independent
Medical Examinations and Peer Reviews. From the very beginning the goal of MES has been to
ensure exceptional service and quality report
s by independent professionals who consistently
express their medical opinions accurately, objectively and timely, thereby assisting the process of
truly effective claims resolution.

Over the years MES has become recognized for setting the standard in the
field of professional
medical opinions. MES provides the benchmark for the industry. We will continue to maintain our
standards for excellence through innovation that enable the claims community to accurately
address every type of disability claim.

Now, ov
er 30 years later, MES Solutions is the largest freestanding provider of Independent
Evaluation Services in the nation. We have built our company brick by brick since 1978. Every
aspect of MES is fully integrated organizationally, structurally and philosop
hically. This can only be
accomplished by an organization committed to organic growth as we have been for nearly three
decades. We are a closely held, veteran and employee owned business, committed to our clients
for the long
-
term.


2) LOCATIONS: The cor
porate headquarters are in The Woodlands, TX. Our division, Veterans
Evaluation Services (VES), is located in Houston. MES has many other offices throughout the
United States.

3)

STRUCTURE: The following simplified structure chart is not comprehensive, but

shows some
of the key players and parts of MES with which you should be familiar





WHO TO CONTACT WHEN YOU HAVE QUESTIONS


E
-
mail address for physician assistance:

vesphysicianhelp@mesgroup.com


A
pril Harris (Associate Director of Development and Training)

(512) 749
-
6128
-
cellular

(713) 255
-
5627
-

office

(832) 485
-
0359
-

fax

April.Harris@mesgroup.com


Lauren Sparkman (Associate Director of Development

and Training)

(210) 771
-
5277
-

cellular

(713) 255
-
5627
-

office

(832) 485
-
0358
-

fax

Lauren.Sparkman@mesgroup.com


Marcia Udin (Director of National Network Development)

(281) 513
-
1379
-

cellular

(832) 485
-
0223
-

fax

Marcia.Udin@mesgroup.com


Regional Managers E
-
mail contact information:


Jason Webster (Indiana and Iowa)

Jason.Webster@mesgroup.com

(317) 691
-
816
0


Andrew Graham (Texas)

Andrew.Graham@mesgroup.com

(972) 742
-
4774


Angela Hosler (Ohio)

Angela.Hosler@mesgroup.com

(248) 320
-
9277









THE VA PROCESS


Our contract with VA requires us to provide you with information about:



a basic overview of VA programs



available sources of veteran assistance



understanding of the core claims adjudication process (what the claimant may
expect a
fter the exam, who makes the decision, who to contact for more info)


BASIC OVERVIEW OF VA PROGRAMS:

VA provides many different kinds of benefits
and assistance to veterans. These include healthcare, home loans, vocational training
and disability benefit
s, to name just a few.


AVAILABLE SOURCES OF VETERAN ASSISTANCE:

VA’s toll
-
free number is 1 (800)
827
-
1000. The website is www.va.gov. Many states and counties provide assistance to
veterans as well
-

those numbers can be found in the government pages o
f the
telephone book. Private veterans’ service organizations like Disabled American
Veterans, the American Legion, Veterans of Foreign Wars and many others can also be
found in the phone book.


VA’S PROCESS:

The process begins when a veteran or active d
uty service person
files a claim with VA for disability benefits. VA may then request an examination from a
VA medical facility or a contractor like MES.


When we receive an exam request, our job is to
-



schedule the appointment(s)



get the report(s) from
the doctor(s)



make sure every report meets VA's strict and complex requirements



deliver the final product to VA


We're just the middleman, so to speak. We provide high quality, on
-
time exam reports to
VA. We don't make the decision on the veteran's claim

and
neither does the examiner
.
That's VA's job.


VA will consider all the evidence
-

which might include the medical records from military
service, private medical records, VA treatment records, our exam report, non
-
medical
records, etc. VA applies appl
icable law and regulation to all that evidence and then
makes the decision. They will notify the claimant in writing of that decision and of his or
her right to appeal if the decision is unfavorable. As always, 1 (800) 827
-
1000 is the
best way for the cl
aimant to contact the VA to find out how the claim is progressing
and/or ask any questions.


Please note that the VA is our client, per the contract. The VA owns the information we
are generating. Per the contract,
neither we nor you are allowed to share

the exam
report or diagnostic results with the claimant
. Requests for this information should be
referred to (800) 827
-
1000. Please ensure you shred all hard copy information and
delete all electronic data pertaining to the claimant after the report has

been delivered to
VA. (which will be when the claimant’s name disappears from the listing on your MES
provider portal page)


IN AN EMERGENCY
: In a medical emergency, please assist the claimant, follow
state guidelines and call 911 as appropriate. Pleas
e immediately notify MES at

1 (877) MES
-
VETS of the situation so we can provide additional guidance.


Performing a C&P Exam


1)

Follow the worksheets provided to the letter.

Any deviation will result in a QA
inquiry.


2)

If medical records were sent to you, p
lease review those completely.


3)

Ensure appropriate attitude towards veterans and their unique circumstances.




Please do not keep claimants waiting. If claimant will be seen more than 15
minutes after the scheduled appointment time please keep them informe
d
regarding any delays.



Greet the claimant.



Briefly explain the exam you are about to provide, i.e. conditions to be
evaluated, purpose of exam is

not treatment but evaluation of disabilities per
VA guidelines.




Keep in mind the unique circumstances of our

claimants. Please treat them
with the respect and courtesy they deserve for their service to our country.



At the end of your exam ask the claimant if he or she has any questions.


4)

If claimant brings up additional conditions:


a)

DO examine those additional c
onditions if we have requested a 1010 head to
toe complete physical.

b)

If claimant is being seen for a systemic condition then evaluate all related
conditions brought up by claimant or found on exam. Systemic diseases can
include: Diabetes Mellitus, Heart D
isease, Lupus, Multiple Sclerosis, etc.

c)

If the exam is not a 1010 or does not involve a systemic disease please
evaluate only the conditions requested by the VA.


5)

For each condition being evaluated we need:



A complete history



Objective findings



Diagnostic
results, if any



Diagnosis


6) FEMALE CLAIMANTS: VA requires that “all gynecological, rectal/anal and breast
examinations are performed by a physician in the presence of a female assistant for
female patients.” Please ensure this requirement is met.

7) WAIV
ER FORM: If a claimant declines a test or any part of an exam, or a female
claimant declines the right to have a chaperone present for a gynecological,
rectal/anal or breast exam, this must be documented in the report. It is important to
explain to the cla
imant that VA requested the test/exam because that information is
needed to make a decision on the claim for VA benefits. If the claimant declines, that
may mean VA will not be able to grant the claim.

Please call 1 (877) MES
-
VETS to
obtain a simple waiver

form to document the situation. We will routinely provide this form to
you for general medical exams and other exams involving gynecological, rectal/anal or breast
exams.


8) Perform all requested diagnostics unless medically contraindicated (must be
docu
mented in report.) If additional diagnostics are needed to render a diagnosis
please contact MES for prior approval.


Please note if symptom magnification is suspected, the examiner
should state why.

DIAGNOSES DOS AND DON’TS


DOs
:

1)

DO

base your diagnosis

on current objective findings and diagnostic results.


2)

If no diagnosis can be determined
DO

explain in detail (i.e. “no pathology to
render a diagnosis”).


3)

If additional testing is needed to render a diagnosis
DO

call MES for approval.


4)

DO

ensure that ea
ch diagnostic has been received, reviewed, and noted in report
before making your final diagnosis.


5)

If you’re changing an established diagnosis
DO

explain why.


DON’TS

1)

DO NOT

volunteer an opinion on whether a condition is related to military service
unless

specifically asked to do so.


2)

DO NOT

substitute symptoms, such as pain, elevated blood pressure, arthralgia,
etc for diagnoses such as strain, hypertension, arthritis, etc.


3)

DO NOT

use terms such as “differential diagnosis,” “History of’” “may be due to,

“likely,” “residuals of,” “rule out,” “pre,” etc.

Expressing Medical Opinions


Occasionally you may be asked to furnish an Independent Medical Opinion (IMO). An
IMO is a question outside the scope of the worksheet which can only be answered after
revie
wing records.


Sometimes the VA will ask the examiner to answer a specific question based on exam
findings and clinical expertise, but these situations do not require records review and are
not considered IMOs.


Please do not give opinions unless they are
specifically requested. When giving an
opinion, please answer the specific question and provide a rationale. The question will
often be posed with the phrase, “at least as likely as not.” The best way to answer is with
one of the following:




“is due to” (
100% certain)



“more likely than not” (greater than 50% certain)



“at least as likely as not” (equal to 50% certain)



“not at least as likely as not” (less than 50% certain)



“is not due to” (0%)


The most common type of opinion request regards a causal relati
onship between
events, injuries, and/or illness during military service and the claimed disability.



AUDIOLOGIST
EXAMIN
ATIONS


Worksheets Utilized for this section:

1) Hearing Loss and Tinnitus (Worksheet 4010)

AUDIOLOGICAL EXAMINATIONS


Reporting Test

Results


History:

Audiologist reports claimant’s chief complaints, situations of greatest
difficulty, pertinent medical, family, social, and military history, and history of
military, occupational, and recreational noise exposure.


Physical Exam
:



Auricle
:
Note deformities, cicatrices, ulcerations, or other
dermatologic and cartilaginous abnormalities.



External canal:
State if there is any exudate. If exudate is present
state if it is serous, purulent, sanguineous, mucoid, odorous,
profuse, scanty and/or p
ulsating. Note any abnormality in size or
shape of canal. Also note if there is edema, and/or erythema. If
lumen is obstructed, state whether the cause is cerumen, foreign
body, or exudate
.



T
ymp
anic Membrane:
Report any abnormality in the landmarks
indicat
ing scarring, retraction, bulging, and/or inflammation. Note
and describe any perforations and their size and position (marginal
or central).



The Tympanum:
A detailed examination should allow evaluation of
an infectious process in the middle ear.

Diagnosis

section:
Audiologist summarizes audiologic test results. The
audiologist must also note if medical follow
-

up is needed for an ear or hearing
problem and whether there is a problem that, if treated, might change hearing
thresholds.




Q
uantitative procedure
s
: calibrated audiometry

Audiogram
:


Rig
ht

Ear

A

B

C

D

E


Aver
age


Left

Ear

A

B

C

D

E


Average


500

1000

2000

3000

4000

(B+C
+D+
E/4)

500

1000

2000

3000

4000

(B+C+D+E/4)

XdB

XdB

XdB

XdB

XdB

XdB

XdB

XdB

XdB

XdB

XdB

XdB


1. If any one “X” value in boxes

A
-
E is
>

or = to 40, VA concedes there is
hearing loss.

2. If

at least

three values of “X” are
>

or = to

26, VA concedes there is
hearing loss.




Qualitative tests
: whispered voice tests and tuning fork tests
(Note: Qualitative procedures do not substitute

for calibrated
audiometry as measures of hearing impairment or disability)

Speech Recognition Score: Maryland CNC test
:


_________% right ear

__________% left ear


3. If the above values are below 94%, VA concedes there is hearing loss.


Conducting audio
metric tests
:




Calibration:
Audiometers utilized in basic audiological procedures
are calibrated to the American Nation Standards Institute.




Approved rooms:
Tests must be conducted in approved sound
treated rooms.




Presentation of stimuli:
Basic tests inv
olve the presentation of
pure tones or recorded speech material. Bone conduction involves
the presentation of stimuli through a bone vibrator located on the
mastoid process or the forehead.




Examiner requirement:
An examination of hearing impairment
must b
e conducted by a state
-
licensed audiologist.




Basic testing:
Basic evaluation includes a controlled speech
discrimination test using an approved recording of the Maryland
CNC test and pure tone audiometry.




Details of testing:
Bone conduction tests are obt
ained when the
air conduction thresholds are poorer than 15dB HL.




Speech reception threshold:
The speech reception threshold
(SRT) is defined as the level (in dB HL) at which the claimant
correctly identifies 50
%

of a set of two
-
syllable words.




Speech r
ecognition tests:
Speech recognition tests involve the
presentation of approved monosyllabic words. Speech recognition
must be obtained with a VA
-

approved recording of the Maryland
CNC Test. Audiologist presents word lists at increasing intensity
levels u
ntil no further change in speech recognition score occurs.
However, presentation levels will not exceed the patient’s level of
discomfort or 105 dB HL, whichever is lower. Maximum speech
recognition score is reported.


Note: Hearing Impairment according to

VA Compensation and
Pension Examination is described as disabling when pure tone
thresholds at 500, 1000, 2000, 3000, and 4000 Hz are 40 dB HL or
greater, or when pure tone thresholds for at least three of these
frequencies are 26 dB HL or greater; or whe
n speech recognition
scores are less than 94%.


Classifying Hearing Impairment




Mild Hearing Loss:
When the four frequency (1000, 2000,
3000, and 4000 Hz) pure tone average is 26 to 40dB HL. May
cause difficulty hearing faint speech or normal speech in

the
presence of background noise.




Moderate Hearing Loss:

When the pure tone average is 41 to
54 dB HL. May cause difficulty with speech at normal
conversational levels, especially when background noise is
present.




Moderately Severe Hearing Loss:
When th
e pure tone
average is 55
-
69 dB HL. May have difficulty hearing or
understand all but loud speech. Speech recognition may be
nearly impossible in the presence of background noise.




Severe Hearing Loss
: When the pure tone average is 70 to 89

dB HL. May have

extreme difficulty understanding spoken
words, even in quite situations.




Profound Hearing Loss:
When the pure tone average is 90 dB
HL or worse. A patient with profound hearing loss is functionally
deaf and may not understand even amplified sounds.


Clas
sification of Hearing Loss




Conductive hearing loss
: Due to lesions hat reduce
transmission of sound through the external auditory canal,
tympanic membrane, or middle ear. If only conductive hearing
loss is present, cochlear function will be normal




Sensor
ineural hearing loss
: Occurs when there are lesions of
the cochlea and auditory nerve.




Mixed hearing loss
: Involve both conductive and sensorineural
components.




Central hearing loss
: Lesions of the central nervous system
from the brainstem to the auditor
y cortex.


Note: Audiologists are qualified to perform site of lesion tests to
differentiate these types of hearing loss.


Diagnosing Tinnitus Based on Claimant’s
History




Specify frequency
: did the claimant report that the tinnitus is
constant or intermi
ttent? Please include this in the diagnosis.



Specify laterality
: did the claimant report that tinnitus occurs in
one or both ears? Please include this in your diagnosis.